Claims Analytics – Analytical Techniques used in Identifying Claim Frauds

Claims Analytics - Analytical Techniques used in Identifying Claim Frauds

To balance the healthcare losses and to raise the overall value of a healthcare organization, claims analytics is the solution. Beyond the difficulties of meeting healthcare reforms, payers are handling complications, like changing consumer behavior and payment expectations, while also looking for customer attrition, waste and fraudulent claims and cost of operations.

For most industry players, claims and related modification costs add to more than 80% of the expense – the single biggest cost directly affecting the profits. This makes it basic for them to control claims related expenses. With a specific end goal to address these difficulties successfully, payers need to invest in analytical solutions to draw actionable insights from the incoming, outgoing and current data to improve organizational efficiency and productivity.

As of now payers in the healthcare sectors are facing some roadblocks that hinder company growth:

  1. Data Integration – Inability to impeccably integrate data from multiple platforms for operational, performance, executive reporting and analytical point of view.
  2. Multisource data platforms – Data stored in structured and unstructured form is often overlooked.
  3. Lacking Business Insights – Stemming for knowing where to find the right information or what to do with available data.

What does Claims Analytics offer?

Comprehensive analytical solutions empower healthcare insurers to settle on fact based decisions. Its key segments involve a versatile organizing system, dimensional models, BI stages, and portability. The analytical tools and platforms produce reports, KPIs and dashboards to quantify business performance. The three-staged, ‘module’ arrangement is anything but difficult to use, and comes with in-built ETL, DW, and BI abilities which supporters organizations and bolster choices including cloud. Also, it gives availability and access to analytics on multiple devices, for example, web, mobile and tablets and the capacity to successfully:

  • Create operational reports
  • Monitor waste and fraud claims
  • Conduct prescient/and what if analysis
  • Provide managers a thorough official dashboard

How doe claims analytics deliver?

The arrangement simplifies analytics by taking out the complex environment of numerous service teams, merchants, Business and IT divisions. It quickens the build out of the platform, and accelerates data insights with defined logic. Claims productivity is further improved by deploying modeling and analysis to track fraudulent claims, and provide meaningful business insights for superior decision-making.

Insurers generate large volumes of customer data, such as policy details, previous claims and information gathered from adjusters. This data can be used in combination with data from industry sources such as NICB to run predictive analytics to identify fraudulent claims early in the claims process.

Inniti hosts a number of healthcare claims related services that benefits payers in many ways. Our core insurance services cover data validation and correction service for in-stream claim processing. It makes it simple to determine whether submitted provider information on a claim is accurate, current and valid, therefore reducing the need for costly manual intervention.

The main advantages of a third-party claims analytics services include:

  • You can avoid provider and financial data inconsistencies between the claim submission and the provider file.
  • Reduce errors in claims payments
  • Improve ability to identify potentially fraudulent submissions
  • Lower the chance for inaccuracies in data warehouse reporting and analysis

Whether healthcare payers like it or not, but claims analytics in the insurance sector is a must for a productive organization workflow and healthy bottom-line. #InnitiCounts

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